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Alcohol is the drug of choice among youth. Many young people are experiencing the consequences of drinking too much, at too early an age. As a result, underage drinking is a leading public health problem in this country.

Research also shows that many adolescents start to drink at very young ages. In 2003, the average age of first use of alcohol was about 14, compared to about 17 1/2 in 1965 (7,8). People who reported starting to drink before the age of 15 were four times more likely to also report meeting the criteria for alcohol dependence at some point in their lives (9). In fact, new research shows that the serious drinking problems (including what is called alcoholism) typically associated with middle age actually begin to appear much earlier, during young adulthood and even adolescence.

Other research shows that the younger children and adolescents are when they start to drink, the more likely they will be to engage in behaviors that harm themselves and others. For example, frequent binge drinkers (nearly 1 million high school students nationwide) are more likely to engage in risky behaviors, including using other drugs such as marijuana and cocaine, having sex with six or more partners, and earning grades that are mostly Ds and Fs in school (10).

Research shows that COAs may have subtle brain differences which could be markers for developing later alcohol problems (28). For example, using high-tech brain-imaging techniques, scientists have found that COAs have a distinctive feature in one brainwave pattern (called a P300 response) that could be a marker for later alcoholism risk (29,30). Researchers also are investigating other brainwave differences in COAs that may be present long before they begin to drink, including brainwave activity recorded during sleep (31) as well as changes in brain structure (32) and function (33).

Some studies suggest that these brain differences may be particularly evident in people who also have certain behavioral traits, such as signs of conduct disorder, antisocial personality disorder, sensation-seeking, or poor impulse control (34–38). Studying how the brain’s structure and function translates to behavior will help researchers to better understand how predrinking risk factors shape later alcohol use. For example, does a person who is depressed drink to alleviate his or her depression, or does drinking lead to changes in his brain that result in feelings of depression?

Other hereditary factors likely will become evident as scientists work to identify the actual genes involved in addiction. By analyzing the genetic makeup of people and families with alcohol dependence, researchers have found specific regions on chromosomes that correlate with a risk for alcoholism (39–41). Candidate genes for alcoholism risk also have been associated with those regions (42). The goal now is to further refine regions for which a specific gene has not yet been identified and then determine how those genes interact with other genes and gene products as well as with the environment to result in alcohol dependence. Further research also should shed light on the extent to which the same or different genes contribute to alcohol problems, both in adults and in adolescents.

Environmental Aspects—Pinpointing a genetic contribution will not tell the whole story, however, as drinking behavior reflects a complex interplay between inherited and environmental factors, the implications of which are only beginning to be explored in adolescents (43). And what influences drinking at one age may not have the same impact at another. As Rose and colleagues (43) show, genetic factors appear to have more influence on adolescent drinking behavior in late adolescence than in mid-adolescence.

Environmental factors, such as the influence of parents and peers, also play a role in alcohol use (44). For example, parents who drink more and who view drinking favorably may have children who drink more, and an adolescent girl with an older or adult boyfriend is more likely to use alcohol and other drugs and to engage in delinquent behaviors (45).

Researchers are examining other environmental influences as well, such as the impact of the media. Today alcohol is widely available and aggressively promoted through television, radio, billboards, and the Internet. Researchers are studying how young people react to these advertisements. In a study of 3rd, 6th, and 9th graders, those who found alcohol ads desirable were more likely to view drinking positively and to want to purchase products with alcohol logos (46). Research is mixed, however, on whether these positive views of alcohol actually lead to underage drinking.

WHAT ARE THE HEALTH RISKS?
Whatever it is that leads adolescents to begin drinking, once they start they face a number of potential health risks. Although the severe health problems associated with harmful alcohol use are not as common in adolescents as they are in adults, studies show that young people who drink heavily may put themselves at risk for a range of potential health problems.

Brain Effects—Scientists currently are examining just how alcohol affects the developing brain, but it’s a difficult task. Subtle changes in the brain may be difficult to detect but still have a significant impact on long-term thinking and memory skills. Add to this the fact that adolescent brains are still maturing, and the study of alcohol’s effects becomes even more complex. Research has shown that animals fed alcohol during this critical developmental stage continue to show long-lasting impairment from alcohol as they age (47). It’s simply not known how alcohol will affect the long-term memory and learning skills of people who began drinking heavily as adolescents.

Liver Effects—Elevated liver enzymes, indicating some degree of liver damage, have been found in some adolescents who drink alcohol (48). Young drinkers who are overweight or obese showed elevated liver enzymes even with only moderate levels of drinking (49).

Growth and Endocrine Effects—In both males and females, puberty is a period associated with marked hormonal changes, including increases in the sex hormones, estrogen and testosterone. These hormones, in turn, increase production of other hormones and growth factors (50), which are vital for normal organ development. Drinking alcohol during this period of rapid growth and development (i.e., prior to or during puberty) may upset the critical hormonal balance necessary for normal development of organs, muscles, and bones. Studies in animals also show that consuming alcohol during puberty adversely affects the maturation of the reproductive system (51).

PREVENTING UNDERAGE DRINKING WITHIN A DEVELOPMENTAL FRAMEWORK
Complex behaviors, such as the decision to begin drinking or to continue using alcohol, are the result of a dynamic interplay between genes and environment. For example, biological and physiological changes that occur during adolescence may promote risk-taking behavior, leading to early experimentation with alcohol. This behavior then shapes the child’s environment, as he or she chooses friends and situations that support further drinking. Continued drinking may lead to physiological reactions, such as depression or anxiety disorders, triggering even greater alcohol use or dependence. In this way, youthful patterns of alcohol use can mark the start of a developmental pathway that may lead to abuse and dependence. Then again, not all young people who travel this pathway experience the same outcomes.
Perhaps the best way to understand and prevent underage alcohol use is to view drinking as it relates to development. This “whole system” approach to underage drinking takes into account a particular adolescent’s unique risk and protective factors—from genetics and personality characteristics to social and environmental factors. Viewed in this way, development includes not only the adolescent’s inherent risk and resilience but also the current conditions that help to shape his or her behavior (52).
Children mature at different rates. Developmental research takes this into account, recognizing that during adolescence there are periods of rapid growth and reorganization, alternating with periods of slower growth and integration of body systems. Periods of rapid transitions, when social or cultural factors most strongly influence the biology and behavior of the adolescent, may be the best time to target delivery of interventions (53). Interventions that focus on these critical development periods could alter the life course of the child (54), perhaps placing him or her on a path to avoid problems with alcohol.
To date, researchers have been unable to identify a single track that predicts the course of alcohol use for all or even most young people. Instead, findings provide strong evidence for wide developmental variation in drinking patterns within this special population (55,56).

INTERVENTIONS FOR PREVENTING UNDERAGE DRINKING
Intervention approaches typically fall into two distinct categories: (1) environmental-level interventions, which seek to reduce opportunities for underage drinking, increase penalties for violating minimum legal drinking age (MLDA) and other alcohol use laws, and reduce community tolerance for alcohol use by youth; and (2) individual-level interventions, which seek to change knowledge, expectancies, attitudes, intentions, motivation, and skills so that youth are better able to resist the prodrinking influences and opportunities that surround them.

Environmental approaches include:

Raising the Price of Alcohol—A substantial body of research has shown that higher prices or taxes on alcoholic beverages are associated with lower levels of alcohol consumption and alcohol-related problems, especially in young people (57–60).

Increasing the Minimum Legal Drinking Age—Today all States have set the minimum legal drinking at age 21. Increasing the age at which people can legally purchase and drink alcohol has been the most successful intervention to date in reducing drinking and alcohol-related crashes among people under age 21 (61). NHTSA (1) estimates that a legal drinking age of 21 saves 700 to 1,000 lives annually. Since 1976, these laws have prevented more than 21,000 traffic deaths. Just how much the legal drinking age relates to drinking-related crashes is shown by a recent study in New Zealand. Six years ago that country lowered its minimum legal drinking age to 18. Since then, alcohol-related crashes have risen 12 percent among 18- to 19-year-olds and 14 percent among 15- to 17-year-olds (62). Clearly a higher minimum drinking age can help to reduce crashes and save lives, especially in very young drivers.

Enacting Zero-Tolerance Laws—All States have zero-tolerance laws that make it illegal for people under age 21 to drive after any drinking. When the first eight States to adopt zero-tolerance laws were compared with nearby States without such laws, the zero-tolerance States showed a 21-percent greater decline in the proportion of single-vehicle night-time fatal crashes involving drivers under 21, the type of crash most likely to involve alcohol (63).

Stepping up Enforcement of Laws—Despite their demonstrated benefits, legal drinking age and zero-tolerance laws generally have not been vigorously enforced (64). Alcohol purchase laws aimed at sellers and buyers also can be effective (65), but resources must be made available for enforcing these laws.

Individual-focused interventions include:

School-Based Prevention Programs—The first school-based prevention programs were primarily informational and often used scare tactics; it was assumed that if youth understood the dangers of alcohol use, they would choose not to drink. These programs were ineffective. Today, better programs are available and often have a number of elements in common: They follow social influence models and include setting norms, addressing social pressures to drink, and teaching resistance skills. These programs also offer interactive and developmentally appropriate information, include peer-led components, and provide teacher training (66).

Family-Based Prevention Programs—Parents’ ability to influence whether their children drink is well documented and is consistent across racial/ethnic groups (67,68). Setting clear rules against drinking, consistently enforcing those rules, and monitoring the child’s behavior all help to reduce the likelihood of underage drinking. The Iowa Strengthening Families Program (ISFP), delivered when students were in grade 6, is a program that has shown long-lasting preventive effects on alcohol use (69,70).